<p>A Novel Sequential Docking Technique: Use of Femtosecond Arcuate Keratotomy and Femtosecond Assisted Cataract Surgery Using a Pupil Expansion Ring on a Patient with Intraoperative Floppy Iris Syndrome</p>

Abstract

The purpose of this study was to evaluate the efficacy of a novel double-docking technique, incorporating the use of femtosecond laser arcuate keratotomy (FSAK) in correcting lowdegree astigmatism and Malyugin ring, in a patient with intraoperative floppy iris syndrome (IFIS). Methods: A case report of a 72-year-old man with grade 4 cataract, low-degree astigmatism (<2D), and IFIS (pupil size <4 mm, intraoperatively) is presented. The patient underwent cataract surgery using a femtosecond laser to treat low-degree astigmatism because the patient requested for the use of a multifocal intraocular lens (IOL). The first docking was performed to complete arcuate keratotomy, produce the mainparacentesis incisions, and create clear corneal incisions. Insertion of the Malyugin ring was performed after the first docking, whereas the second one was executed to complete continuous curvilinear capsulotomy and lens fragmentation. The patient's uncorrected visual acuity (UCVA) was measured pre-and post-operatively. The complications were evaluated post-operatively and 3 months later during the follow-up visit. Results: The patient's UCVA for distance improved from 0.3 (6/12 Snellen equivalent) to 0 (6/6 Snellen equivalent) logMAR post-operatively. During the follow-up visit, the patient's uncorrected near visual acuity was at J2. His corneal astigmatism changed from −1.0 Diopter @177°pre-operative to −0.12 D @173°post-operative. No other intraoperative or postoperative complications were observed. Conclusion: The double-docking technique, with the use of FSAK, and Malyugin ring produced successful surgical outcomes for the patient. The benefits of this technique allow surgeons to avoid changing the shape of the patient's cornea from the injection of the viscoelastic device into the anterior chamber, which could lower the femtosecond laser's precision and docking location.

Cataract surgery in setting of ocular surface disease

“…Ocular surface toxicity from preoperative and postoperative topical treatment should be minimized selecting preservative free formulation and stopping them when no lo longer needed, or by opting for intracameral/intravitreal/or sustainedrelease medications. The prescription of topical NSAID, effective in reducing the incidence and degree of postoperative cystoid macular edema, has also been associated with slow corneal epithelial healing and sterile melting, especially in patients with severe OSD and Sjogren's syndrome; the use of topical NSAID postoperatively in such patients should be considered judiciously [8,15,16,19,[67][68][69][70].…”

Dilation devices in cataract surgery

“…Phacoemulsification is then performed and the ring is removed after intraocular lens implantation [40]. The Malyugin ring has also been found to be a useful intraoperative tool to assist the surgeon in cases of cataract surgery in the presence of iridoschisis and both anterior and posterior synechiae, to avoid intraoperative positive vitreous pressure during triple procedures, to manage small pupil in the setting of femtosecond laser-assisted cataract surgery (FLACS), and pediatric cataract surgery [41][42][43][44][45][46][47][48][49] (video: https:// www.youtube.com/watch?v=_LisTIDv2OA and https://www.youtube.com/watch?v=2K0fsuZWktA).…”

Dealing with floppy iris syndrome

“…Another modified surgical technique is modified hydrodissection with insertion of the phacoemulsification tip into the main ocular incision with hydrodissection performed through a side port incision [67 ▪▪ ]. Recently, Lin et al [68 ▪ ] proposed a double-docking method that allows for use of femtosecond assisted cataract surgery in patients with IFIS.…”